Legislation pushes involuntary mental health treatment

Maryland lawmakers are moving to make it easier to medicate mental hospital patients against their will, while examining the idea of court-ordered therapy for mentally ill people who aren't hospitalized.

The legislation is based partly on recommendations from a panel convened by Gov. Martin O'Malley after the 2012 shootings at Sandy Hook Elementary in Newtown, Conn. That case prompted a national debate about the adequacy of care for mentally ill Americans.

But while some mental health advocates have long sought additional tools to better manage treatment — for the sake of the patient and public safety — the proposals have created a rift in the health care community. Some argue such measures are inhumane and unconstitutional.

"This is part of the dilemma in choosing between, on the one hand, necessary treatment, and having high respect for people's individual rights," said Del. Dan Morhaim, the General Assembly's only physician and sponsor of the medication legislation. "We are trying to strike the right balance and really help those who need it."

The state Department of Health and Mental Hygiene supports legislation that would expand the circumstances under which a doctor could medicate mental health patients without their consent. In those cases, as a check and balance, a review must be done by a clinical panel.

Health officials argue that the longer patients go without treatment, the worse their illness and chances for recovery become.

Some lawmakers want further study of a proposal that would allow patients to be forced to get outpatient treatment. They also want an outside panel to study other alternatives, such targeted outreach efforts called "assertive community treatment" that engage those with mental illnesses rather than forcing treatment.

Other measures that would make it easier to have people committed are less assured of passage. One bill would clarify the criteria needed to have somebody hospitalized when they have a psychotic break, but opponents warned the commitment process could be abused. A Senate committee voted against that proposal.

The state health department supports clarifying the standards for hospitalization of mentally ill patients, but it would rather see changes made through regulation, not legislation.

Under the law, patients must be deemed a danger before they can be hospitalized, but practitioners and institutions widely interpret the definition of dangerous.

The health department recently studied deficiencies in the state's behavioral health system that led to periods without care for those with schizophrenia, bipolar disorder, major depression and other conditions. Those breaks can on rare occasions lead to dangerous situations.

"There are some people that may not be in a position where they can make decisions about their treatment," said Dr. Gayle Jordan-Randolph, deputy secretary for behavioral health at the Department of Health and Mental Hygiene, who chaired the panel.

But balancing the need for treatment against individual rights is difficult, experts said.

Forcing people into treatment may not be effective, said Linda Raines, chief executive officer of the Mental Health Association of Maryland. She said it might be more effective to engage patients and help them understand they need help.

"Why don't we give people the option first to let them self-select what will make them better," Raines said.

She called some of the legislation proposed in the General Assembly a "substantial and frightening step backward" that would merely increase the number of people who are institutionalized.

Others say steps must be taken to ensure the mentally ill get the care they need before a crisis occurs. In fiscal year 2012, an analysis of Medicaid data found that 588 people, or less than 1 percent of the state's mental health population, accounted for one-quarter of all emergency department visits. Those patients visited the emergency department six or more times in a year. Many are believed to have a mental disorder called anosognosia, which causes them not to recognize that they are sick.

Some families of mentally ill patients say they can't afford to wait for more studies.

Dr. Steven Sharfstein, CEO of Sheppard Pratt Health System, supports mandatory treatment options because he has seen families desperate to help their loved ones. Doctors sometimes tell them the only way their relatives can get help is if they get arrested, he said.

"Families will tell you about how frustrated and frightened they are because their family member won't get care and how much havoc it creates," Sharfstein said.